Southern California Permanente Medical Group Research Articles

Why Can't I Stop Smoking: Predictors of Tobacco Use and Quit Rates in the Freedom From Tobacco Program.

Introduction As the leading cause of preventable chronic diseases in adults 18 years and older, tobacco usage in the U.S. results in over 20 million premature deaths annually. Current smokers might need extra support on the path to successfully quitting. Aim To evaluate the influence of predictors of smoking-on-smoking cessation in the Freedom From Tobacco Program (FFT) offered by Southern California Permanente Medical Group (SCPMG). Methods This was a quasi-experimental study to evaluate rates of smoking cessation among participants in the FFT program.There were 471 participants in the study.Factors of the Social Ecological Model (SEM) and demographics were examined to determine if they could predict tobacco cessation.The SEM suggests that an individual's behavior is integrated into a network of intrapersonal characteristics, interpersonal processes, institutional factors, community features, and public policy. In particular, the study mainly addressed the institutional factor. It was promoted within a Health Management Organizationand the interpersonal process because it was a group intervention. Findings After multiple regression analyses with all predictors from the SEM and demographics, the only significant predictor was the number of previous attempts to quit. Smokers who tried to stop four or more times in the past were 2.6 times (p<0.03) more likely to quit than those who tried fewer times. As we are aware, this was the first time this result was found for programs implemented by Health Management Organizations. The general quit rate at 12 months for the FFT program was 43.1%. Conclusion As the only predictor of quitting in this study was the number of previous attempts to quit smoking, the recommendation is to develop longer-term smoking cessation programs or a longer follow-up to facilitate smokers who relapse to go back and try to quit again. Another recommendation is to identify the main reasons for relapse and try to address these factors in further interventions.

High Grade Differentiated Follicular Cell-Derived Thyroid Carcinoma Versus Poorly Differentiated Thyroid Carcinoma: A Clinicopathologic Analysis of 41 Cases.

Criteria overlap for separating between malignant follicular epithelial cell-derived thyroid gland neoplasms with high grade features of increased mitoses and tumor necrosis but lacking anaplastic histology. Patterns of growth, nuclear features, tumor necrosis, and various mitotic index cutoffs are suggested, but a reproducible Ki-67-based labeling index has not been established. Forty-one cases diagnosed as poorly differentiated thyroid carcinoma (PDTC) or high grade differentiated follicular cell-derived thyroid carcinoma (HGDFCDTC) were reviewed, with histologic features, mitotic figure counts, and Ki-67 labeling index reviewed on cases within Southern California Permanente Medical Group from 2010 to 2021 to establish any potential outcome differences. There were 17 HGDFCDTC (nine papillary thyroid carcinoma; eight oncocytic follicular thyroid carcinoma), median age 64years, affecting nine females and eight males. Tumors were large (median, 6.0cm), usually unifocal (n = 13), with only one tumor lacking invasion. Tumor necrosis was present in all; median mitotic count was 5/2 mm2 (median Ki-67 labeling index 8.3%). Three patients had metastatic disease at presentation, with additional metastases in four patients (41.2% developed metastases); 11 were without evidence of disease (median 21.2months); with the remaining six patients alive (n = 4) or dead (n = 2) with metastatic disease (median 25.8months). Criteria associated with an increased risk of developing metastatic disease: widely invasive tumors; age ≥ 55years; male; advanced tumor size and stage; extrathyroidal extension; but not increased mitotic rate or higher labeling index. There were 24 PDTC, median age 57.5years, affecting 13 females and 11 males. Tumors were large (median, 6.9cm), with 50% part of multifocal disease, with three tumors lacking invasion. Insular/trabecular/solid architecture was seen in all tumors; tumor necrosis was present in 23; and median mitotic count was 6/2 mm2 (median Ki-67 labeling index 6.9%). Five patients had metastatic disease at presentation, with additional metastases in 3 patients (29.2% developed metastases); 16 were without evidence of disease (median, 48.1months); with the remaining 8 patients alive (n = 3) or dead (n = 5) with metastatic disease (median, 22.4months). Criteria associated with an increased risk of developing metastatic disease: widely invasive tumors; male; advanced tumor size and stage; extrathyroidal extension; but not increased mitotic rate or higher labeling index. HGDFCDTC shows tumor necrosis, a median Ki-67 labeling index of 8.3%, with a high percentage (41%) of patients developing metastatic disease. Extent of invasion (non-invasive, minimally invasive, angioinvasive, widely invasive) correlates strongly with developing metastatic disease. PDTC presents at a slightly younger age, with large tumors, often in a background of multifocal tumors, with tumor necrosis nearly always seen, a median Ki-67 labeling index of 6.9%, with 29% of patients developing metastatic disease. Separation between groups is meaningful as early metastatic disease is relatively common, but mitotic counts/labeling indices are not different between the groups nor able to potentially risk stratify development of metastatic disease.

Retreatment of Stress Urinary Incontinence After Midurethral Sling With Prior Urethral Bulking.

There is limited current literature regarding the retreatment of stress urinary incontinence (SUI) after midurethral sling (MUS) placement with prior urethral bulking. The objective was to evaluate the retreatment and perioperative complications of MUS placement with prior urethral bulking compared with MUS placement without prior urethral bulking. This was a retrospective cohort study of patients within the Southern California Permanente Medical Group who underwent MUS placement from January 2009 to December 2020. Patients who underwent prior urethral bulking were compared with a control group without prior urethral bulking in a 1:1 ratio matched by age and MUS procedure date. The primary outcome was the retreatment of SUI after MUS placement with prior urethral bulking. Secondary outcomes were perioperative complications. Regression models were used to evaluate associations between retreatment and perioperative complications while controlling for confounding variables. Eighty-five patients who underwent MUS placement with prior urethral bulking were identified and matched with 85 control patients who underwent MUS placement without prior urethral bulking. Patients who underwent MUS placement without prior urethral bulking were more likely to have concomitant surgery. Linear regression analysis controlling for the effect of concomitant surgery revealed no difference in estimated blood loss and operative time between the 2 groups. In logistic regression analysis, there was no difference in the retreatment rate and perioperative complications between groups. We found that the unique treatment combination of MUS placement with prior urethral bulking for recurrent SUI seems to have a similar retreatment rate and perioperative complications as MUS placement without prior urethral bulking.

What does the future hold? Let’s not forget the past

Southern California Permanente Medical Group, Los Angeles, CA The author reports no conflicts of interest. Correspondence to Jennifer M. Weiss, MD, Southern California Permanente Medical Group, 4760 Sunset Blvd., Los Angeles, CA 90027 Tel: +323-783-0399; fax: N/A; e-mail: [email protected].

Laboratory monitoring to reduce adverse drug-related events: a mixed methods study.

BACKGROUND: Therapy with angiotensinconverting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) requires laboratory monitoring to avoid hyperkalemia and acute kidney failure. OBJECTIVE: To assess the frequency of recommended annual serum potassium and creatinine monitoring and determine potential factors associated with care gaps among adults dispensed an ACEI or ARB. METHODS: This mixed-methods study integrated findings from a retrospective cohort study and individual patient interviews. Adults aged 21 years and over within Kaiser Permanente Southern California with at least 180 treatment days of an ACEI and/or ARB in 2015 were included. Patients invited for qualitative interviews included those who did and did not complete the recommended laboratory tests. We assessed the proportion of patients completing both recommended laboratory tests, factors associated with not receiving laboratory monitoring, and patients' insights into barriers and facilitators of recommended monitoring. RESULTS: Of 437,544 patients who received an ACEI or ARB, 9.0% did not receive both a serum potassium and creatinine laboratory test during treatment (defined as a care gap). Lower risk of a care gap was observed for patients with increasing age (rate ratio [RR] per 10-year increase = 0.78, 95% CI = 0.77-0.79); diabetes mellitus (RR = 0.62, 95% CI = 0.60-0.64); hypertension (RR = 0.71, 95% CI = 0.71-0.74); Charlson Comorbidity Index score of at least 2 (RR = 0.62, 95% CI = 0.60-0.64); those who changed medication classes (RR = 0.53, 95% CI = 0.51-0.56); and patients with a cardiologist (RR = 0.81, 95% CI = 0.73-0.90) or nephrologist (RR = 0.60, 95% CI = 0.52-0.69) as their prescribing provider. Twenty-five patients completed the qualitative interviews. Patients often lacked knowledge about the need for laboratory monitoring, cited logistical barriers to accessing the laboratory, and deemed the reminders they received through an outpatient safety program as a facilitator to completing tests. CONCLUSIONS: Given the large patient population on ACEI and ARB medications, monitoring and support strategies such as electronic clinical surveillance could be important in addressing care gaps and potentially reducing adverse drug effects. DISCLOSURES: This project was supported by grant number R01HS024437 from the Agency for Healthcare Research and Quality. The funder had no role in the design of the study; collection, analyses, or interpretation of the data, or decision to submit this manuscript for publication. Harrison, Reynolds, Hahn, Munoz-Plaza, Yi, Fischer, Luong, Sim, Brettler, Handler, and Mittman are employees of the Southern California Permanente Medical Group. Danworth was employed by the Southern California Permanente Medical Group at the time of this study. Singh was partially supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN13-413). Reynolds reports grants from Novartis, Amgen Inc., and Vital Strategies, Resolve to Save Lives, unrelated to this work. Yi reports grants from Novartis unrelated to this work. Kanter has nothing to disclose.

Unhealthy Drinking Behavior and the ATTAIN Solution: Web-based Automated Alcohol Misuse Interventions.

Up to 30% of American adults may have unhealthy drinking behavior, but only 17% get screened. There is promise in improving screening via technology, but there is a lack of published evidence supporting these efforts. We describe the development of Automated Alcohol Misuse Interventions (ATTAIN), an automated, web-based process to screen for and manage adults with unhealthy drinking behavior with minimal involvement of health-care personnel. After creating a strategic business plan, ATTAIN was developed for the Southern California Permanente Medical Group using its integrated model of care, electronic medical records, and patient portal. ATTAIN is based on an automated branching questionnaire that screens for unhealthy drinking behavior and, when applicable, alcohol use disorders, and incorporates questions about readiness to change and interest in medications/counseling to assist with alcohol consumption reduction. Health plan members would be invited via email to fill out the screening questionnaire using the patient portal. Based on their responses, they would receive appropriate automated feedback and a link to a counseling video about the spectrum of alcohol use. Patients' responses would be captured in their medical record and sent to a designated provider for further help as needed. The process would be refined through successive quality improvement pilots. We project that ATTAIN will lead to reduced costs for the Southern California Permanente Medical Group . This effort has paved the way for using ATTAIN to improve patient care and to reduce the costs associated with managing unhealthy drinking, and potentially leads to similar processes for other medical conditions and health-related behaviors.

EP450 - Cytogenomic microarray analysis as a first-tier clinical diagnostic test: Kaiser Permanente, Southern California Permanente Medical Group experience

eP450 - Cytogenomic microarray analysis as a first-tier clinical diagnostic test: Kaiser Permanente, Southern California Permanente Medical Group experience

Fungal prostatitis due to endemic mycoses and Cryptococcus: A multicenter case series.

Fungal prostatitis is exceedingly rare with mostly case reports. Electronic medical records at three medical centers were searched for cases of fungal prostatitis due to endemic mycoses and Cryptococcus over the preceding 10 years. Seven cases were identified from 105 600 prostate biopsies within the Southern California Permanente Medical Group for an incidence of 0.0066%. An additional eight cases were identified from two other health care systems. Excluding four patients without available clinical data, 11 patients were reviewed, most of whom underwent biopsy due to elevated prostate-specific antigen. Four were asymptomatic and the remainder had nonspecific signs or symptoms. All biopsies revealed granulomatous inflammation and fungal organisms. Seven patients had coccidioidomycosis, three patients had cryptococcosis (confirmed in two cases and suspected by organism morphology in the other), and one patient had likely histoplasmosis based on organism morphology. Prolonged antifungal treatment was standard; outcomes were favorable. Fungal prostatitis due to endemic mycoses and Cryptococcus is uncommon and associated with favorable outcomes but generally involves prolonged therapy.

Case Series: Lingual Infarction and Autoamputation in Systemic Lupus Erythematosus.

Southern California Permanente Medical Group, Los Angeles, CA Southern California Permanente Medical Group Los Angeles, CA [email protected] Southern California Medical Group Los Angeles, CA The authors declare no conflict of interest.

Glomerular Diseases in Patients with Diabetes Mellitus: An Underappreciated Epidemic.

The prevalence of nondiabetic kidney disease (NDKD) in patients with diabetes reflects the rising incidence of diabetes in the general population. The most current national prevalence of diabetes in United States adults is at a high of 12.2%. A contributing factor is the obesity epidemic, as 87.5% of diabetic adults are overweight or obese. It is well known that CKD and ESKD cause significant morbidity and mortality in obese and diabetic populations, with an estimated 36.5% of diabetics experiencing CKD (1). The relative risk of ESKD is higher in diabetics, ranging from 6.2 in white populations to 62.0 in Native Americans; of patients who start RRT, 51% are estimated to have diabetes (2). The diagnosis of diabetic kidney disease (DKD) is most often made clinically. However, there is growing awareness of the prevalence of NDKD with or without concomitant diabetic nephropathy (DN) in patients with diabetes. In turn, a large proportion of NDKD found on kidney biopsies is glomerular diseases. This knowledge draws attention to the possibility of undiagnosed, potentially reversible lesions in this population. Here, we review the prevalence and presentation of NDKD in diabetic patients, with a focus on glomerular lesions, and discuss the ways in which diabetes can affect the diagnosis and management of these conditions. A review of native kidney biopsies for evidence of NDKD in diabetics performed at the Columbia Renal Pathology Laboratory in 2011 estimated that 23.5% of patients with native kidney biopsies carry a diagnosis of diabetes, roughly double the prevalence of diabetes in United States adults. Of those patients, 37% had DN alone, 36% had NDKD alone, and 27% had concomitant DN and NDKD (3). A retrospective examination of renal biopsies at the Southern California Permanente Medical Group between 1995 and 2005 found larger proportions of patients with NDKD alone (53.2%) …

Oropharyngeal Squamous Cell Carcinoma in 390 Patients: Analysis of Clinical and Histological Criteria Which Significantly Impact Outcome.

This study evaluates the prognostic impact of several factors in oropharyngeal squamous cell carcinoma (OPSCC), controlling for human papillomavirus (HPV)-associated tumors and stage (American Joint Committee on Cancer 8th edition). All patients in Southern California Permanente Medical Group diagnosed with OPSCC between 2006 and 2012 tested for p16 immunohistochemistry were included. Review of all pathology materials was combined with central p16 testing. Multivariable analyses were performed. The cohort of 390 patients included 342 p16-positive and 48 p16-negative tumors. For all-comers, on univariate analysis, the following factors, when present, were associated with improved patient survival: p16-positive tumor (n = 324, p < 0.001); crypt versus surface tumor location (n = 312, p = 0.004); nonkeratinizing type (n = 309, p < 0.0001); nonkeratinizing with maturation type (n = 37, p < 0.0001); basaloid pattern (n = 284, p = 0.005); and a broad, pushing border of infiltration (n = 282, p = 0.004). Inferior survival outcomes were observed with: age ≥ 55years (p < 0.0001); ≥ 10 pack-year smoking history (n = 183, p = 0.003); increasing tumor stage (p < 0.0001); overt radiographic extranodal extension (ORENE) (n = 58, p < 0.0001); low level IV/Vb lymph node involvement (n = 45, p = 0.0002); a jagged pattern of infiltration (n = 76, p = 0.0004); tumor ulceration (n = 76, p = 0.0004); absent lymphocytic infiltrate (p < 0.0001); and concurrent dysplasia (n = 125, p = 0.009). On multivariable analysis, accounting for patient age, smoking history ≥ 10 pack-years, and TNM stage, for patients with p16-positive disease, advanced TNM stage (p = 0.007), the presence of ORENE (p = 0.0002), and low-neck lymphadenopathy (p = 0.0001) were independent negative prognostic factors for disease free survival (DFS). Older age (p < 0.0001), smoking history ≥ 10 pack-years (p = 0.02), advanced TNM stage (p = 0.0002), ORENE (p = 0.004), and low-neck lymphadenopathy (p = 0.002) were independent negative prognostic factors for OS. Among patients with p16-positive OPSCC, older age, smoking history, advanced stage, ORENE, and low-neck lymphadenopathy were significant negative prognostic factors for DFS and/or OS. Further refinement of staging to incorporate additional lymph node findings may be warranted.

Rethinking Malignancy Risk in Indeterminate Thyroid Nodules with Positive Molecular Studies: Southern California Permanente Experience.

To recognize that thyroid nodules with atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS; Bethesda III) have different risks of malignancy based on genetic mutation and to consider molecular testing of nodules with AUS/FLUS to help avoid unnecessary morbidity or cost. Retrospective cohort study. Multiple locations within Southern California Permanente Medical Group. Patients included those with indeterminate thyroid nodules and AUS/FLUS on 2 separate fine-needle aspirations with positive ThyGenX testing from 2014 to 2017 who underwent thyroid surgery. Patients were classified as having benign or malignant disease. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features was considered benign. A total of 231 patients had repeat AUS/FLUS with positive molecular testing and surgery. The most frequent type of malignancy was papillary carcinoma, followed by follicular carcinoma. The overall prevalence of malignancy in nodules with mutations was 74.0%, although there was considerable variation: BRAF = 100%, RET = 100%, PAX8-PPARγ = 84.6%, HRAS = 70.7%, NRAS = 63.4%, and KRAS = 33%-a statistically significant finding (P < .001). Not all molecular mutations in thyroid nodules with AUS/FLUS have a high risk of malignancy. Of note, patients with BRAF and RET mutations in our population had a 100% risk of malignancy. Patients with PAX, HRAS, or NRAS mutations had a high risk of malignancy, while patients with KRAS mutations had a lower risk of malignancy. Further studies are needed to determine if the presence of certain molecular mutations can help personalize care and aid in the decision for thyroid surgery.

Health Appraisal and the Adverse Childhood Experiences Study: National Implications for Health Care, Cost, and Utilization.

This article describes the origins of the Division of Health Appraisal in Southern California Permanente Medical Group's San Diego Department of Preventive Medicine, which provided a comprehensive and nontraditional array of preventive medicine services to more than 50,000 members a year. The fusion of Health Appraisal with the Positive Choice risk abatement services provided the origins of the now internationally recognized Adverse Childhood Experiences Study and its major implications for the outcomes and costs of medical care.The Health Appraisal system fulfilled the medical evaluation and preventive needs of most adult patients outside of the traditional and costly sickness-care system, provided rapid access to medical care, has been medically reliable and appreciated by patients, and demonstrably reduced the cost of medical care while providing each evaluated member with a comprehensive medical record in a specialized database. The unexpected resistance to this concept's further implementation deserves exploration and understanding given the current problems in medical care.This article will discuss: Health Appraisal development and function; the Health Appraisal process; perspectives on the Health Appraisal product, outcomes, and benefits; and the Positive Choice system that linked Health Appraisal to prevention activities. A proposal for program expansion and the major economic implications of certain Adverse Childhood Experiences Study findings also will be discussed.

Trends in Lipid Screening Among Adults in an Integrated Health Care Delivery System, 2009-2015.

Lipid screening determines eligibility for statins and other cardiovascular risk reduction interventions. To examine trends in lipid screening among adults aged ≥20 years in a large, multiethnic, integrated health care delivery system in southern California. Temporal trends in lipid screening were examined from 2009 to 2015 with an index date of September 30 of each year. Lipid screening was defined as the proportion of eligible members each year who (a) had ever been screened among those aged 20-39 years and (b) had been screened in the previous 6 years for those aged ≥ 40 years. Trends were analyzed by age, gender, and the presence of atherosclerotic cardiovascular disease (ASCVD) or diabetes without ASCVD status. More than 2 million individuals were included each year: 5%-6% had ASCVD (includes those with diabetes), 7%-8% had diabetes without ASCVD, and 87% had neither condition. Among the entire population, lipid screening increased from 79.8% in 2009 to 82.6% in 2015 (P < 0.0001). Among those with ASCVD or diabetes, lipid screening was 99% across all years. Among those without ASCVD or DM, screening increased from 76.9% in 2009 to 80.0% in 2015 (P < 0.0001), with higher screening among women compared with men and lower screening among individuals younger than 55 years. Consistently high rates of lipid screening were observed among individuals with ASCVD or diabetes. In individuals without these conditions, screening increased over time. However, there is room to further increase screening rates in adults younger than 55 years. This manuscript and research work was supported by a contractual agreement between the Southern California Permanente Medical Group and Regeneron Pharmaceuticals and Sanofi U.S. Researchers from Regeneron and Sanofi collaborated on the study design, interpretation of data, and writing of the manuscript. Ling Grant, Harrison, Chang, Hsu, Cheetham, Wei, and Reynolds are employed by Kaiser Permanente Southern California. Scott is employed by Southern California Permanente Medical Group. Boklage is employed by Regeneron, and Romo-LeTourneau is employed by Sanofi. Preliminary results from this study were presented at the American Heart Association Scientific Sessions; November 12-16, 2016; New Orleans, LA.

Pharmacists contribute to integrated health systems' approaches to opioid safety.

“I can’t say enough about the role of a pharmacist in this program,” a regional medical director of quality and clinical analysis told an audience on February 15 while describing Kaiser Permanente’s success at promoting safe and appropriate opioid prescribing. Through the Safe and Appropriate Opioid Prescribing program, the 8-region integrated health system in 4 years reduced by nearly 40% the number of patients who were prescribed opioid dosages of 90 or more morphine milligram equivalents (MME) per day, reported Michael H. Kanter, the quality and clinical analysis medical director for Southern California Permanente Medical Group. A 2016 guideline by the Centers for Disease Control and Prevention (CDC) recommends that primary care providers prescribe opioid dosages of less than 90 MME/day for the treatment of chronic pain. Thomas Emmendorfer, deputy chief consultant for pharmacy benefits management services at the Department of Veterans Affairs, said pharmacists’ one-on-one education of prescribers contributed to the success of the federal group’s Opioid Safety Initiative.

Sinonasal Tract Solitary Fibrous Tumor: A Clinicopathologic Study of Six Cases with a Comprehensive Review of the Literature.

Solitary fibrous tumors (SFTs) are well recognized in the head and neck region, but rarely arise in the sinonasal tract (SNT). Six primary SNT SFTs were identified in the files of Southern California Permanente Medical Group between 2006 and 2017. The patients included five males and one female ranging in age from 33 to 72years (mean 52years), most of whom presented clinically with nasal obstruction. Three tumors involved the nasal cavity alone, one involved the paranasal sinuses, and two involved both the nasal cavity and paranasal sinuses. Histologically, the tumors were characterized by a variably cellular proliferation of cytologically bland spindle cells within a collagenous stroma with prominent interspersed branching vessels. Mitotic activity was low (range 0-2 per 10 high power fields) and there was no evidence of pleomorphism or tumor necrosis. Surface ulceration was noted. By immunohistochemistry, the lesional cells were positive for CD34, STAT6 and bcl-2. Clinical follow up information was available for all patients (range 32-102months; mean 72months). There were no recurrences or metastases and all were alive with no evidence of disease at last follow-up. SFTs rarely affect the SNT, but should be considered in the differential diagnosis of SNT mesenchymal lesions. Immunohistochemical expression of STAT6 can aid in diagnosis and separation of SFT from other spindle cell lesions occurring at this anatomic site. In combination with cases reported in the literature, primary SNT SFT behave in an indolent manner with conservative treatment.

Lean Enablers for Clinical Laboratories

Research in Medical & Engineering Sciences Lean Enablers for Clinical Laboratories Bohdan W Oppenheim1*, Michael H Kanter2, Onie Bueno3, Vincent L Dizon4, Louie M Farnacio5, Paulette L Medina6, Mike M Moradian7, Chiemi Tabata8 and Michael S Tiffert9 1PhD, Professor of Systems Engineering, Associate Director for Healthcare Systems Engineering, Loyola Marymount University, Los Angeles 2MD, CPPS, Regional Medical Director of Quality & Clinical Analysis, Southern California Permanente Medical Group (SCPMG), Executive Vice President, Chief Quality Officer, The Permanente Federation 3Director of Operations, Bacteriology and Molecular Microbiology, SCPMG, Regional Reference Laboratories, Chino Hills 4MBA MT(ASCP) DLM SBB. Director of Operations, Chemistry Services, Kaiser Permanente SCPMG Regional Reference Laboratories 5Director of Laboratory Services, Kaiser Permanente Southern California Regional Reference Laboratory 6Assistant Director of Operations, RRL Bacteriology, Kaiser Permanente SCPMG Regional Reference Lab 7PhD, Director of Operations, Molecular Genetic Pathology Regional Laboratory, Kaiser Permanente SCPMG Regional Reference Laboratories 8Assistant Director of Operations, RRL Automated Chemistry, Kaiser Permanente SCPMG, Regional Reference Laboratories 9MS, Section Manager, Cytogenetics, Regional Genetics Laboratory, Kaiser Permanente SCPMG, Regional Reference Laboratories *Corresponding author: Dr. Bohdan W Oppenheim, Professor of Systems Engineering, Associate Director for Healthcare Systems Engineering, Loyola Marymount University, Los Angeles, USA Submission: October 23, 2017; Published: November 27, 2017 DOI: 10.31031/RMES.2017.02.000543 ISSN : 2576-8816Volume2 Issue4

Vulvar intraepithelial neoplasia: Risk factors for recurrence

ObjectiveWe studied a large population of women with high-grade vulvar intraepithelial neoplasia (VIN) in order to identify patient and treatment-related risk factors for recurrence and progression to cancer. MethodsFor this retrospective cohort study of women with a histologic diagnosis of VIN within Southern California Permanente Medical Group between 1995 and 2007 medical records were reviewed; clinical, demographic and pathologic data were collected. Statistical analyses included Chi-squared and Student's t-tests, univariate and multivariate logistic regression, and cumulative incidence analysis. Results914 patients with high-grade VIN were identified; 784 met inclusion criteria. We found 26.3% recurrences among treated women, with 2.2% progression to cancer (8.2% among those with recurrence). Risk factors for recurrence on multivariate analysis were: age >50years (OR, 1.44; 95%CI 1.01–2.07), immunosuppression (OR 2.08; 95%CI 1.42–3.06), metasynchronous VAIN or CIN (OR 1.76; 95%CI 1.08–2.88) in addition to margin status (OR 8.17; 95%CI 4.60–14.51) and adjacent LSA (OR 9.91; 95%CI 1.53–31.32) or HPV (OR 2.15; 95%CI 1.13–3.37) with excisional treatment. Recurrence rates did not differ significantly by smoking status and treatment modalities. Median time to recurrence was 16.9months; 25% had late recurrences (44–196months). Cumulative incidence analyses of time to recurrence shows a significantly higher risk among patients over age 50 (log-rank p=0.0031). ConclusionWe identified independent risk factors for recurrence including age >50years, immunosuppression, metasynchronous vaginal or intraepithelial neoplasia, positive excision margins, and adjacent lichen sclerosus or human papilloma-virus. Regardless of treatment modality, 25% of recurrences occurred late, highlighting the need for long-term surveillance in women treated for VIN.

Physicians' Perceptions of Volunteer Service at Safety-Net Clinics.

Volunteer physicians are crucial for the operation of safety-net clinics, which provide medical care for uninsured and underinsured populations. Thus, identifying ways to maximize the number of physicians volunteering at such clinics is an important goal. To investigate the perceptions, motivations, functions, and barriers associated with physician volunteering in four safety-net clinics in San Bernardino County, Southern California, a location of great medical need with many barriers to care. The study participants are physicians belonging to the Southern California Permanente Medical Group who use a combination of discretionary time (during regular work hours) and personal time in evening and weekend hours to volunteer their services. The experimental design incorporates a mixed methodology: an online survey of 31 physicians and follow-up interviews with 8 of them. Physicians conveyed uniformly positive perceptions of their volunteer service, and most were motivated by humanitarian or prosocial desires. Volunteering also provided a protective "escape hatch" from the pressures of the physicians' regular jobs. Physicians cited few challenges to volunteering. The most common personal barrier was a lack of time. The most common professional barriers were organizational and supply issues at the clinic, along with the patients' social, transportation, and financial challenges. The results suggest that appealing to physicians' values and faith, and highlighting the burnout-prevention qualities of volunteering, may be key to recruitment and retention of volunteer physicians who serve underserved and underinsured populations in community clinics.

A Large Retrospective Series of Pregnancy and Delivery After Midurethral Sling for Stress Urinary Incontinence.

The aim of this study was to review the complete medical course, including safety, efficacy, and medical decision making, of patients who delivered a pregnancy after the placement of midurethral sling (MUS) within a large health maintenance organization. We conducted a retrospective case series of patients within the Northern and Southern California Permanente Medical Group who were identified based on procedural codes for placement of MUS for stress urinary incontinence. Electronic medical records with MUS code were referenced against records of live births within the health care system. Demographic and clinical data were abstracted through extensive, standardized physician review of the electronic medical records of all identified patients. Twenty-six patients were identified and included in analysis. Sixteen patients had a retropubic MUS, and 10 had a transobturator MUS. Twenty-one of 26 patients reported subjective resolution of urinary incontinence after MUS. Fourteen of the 25 first deliveries after MUS were cesarean section (CS). Of these, 5 CS were elective primary for the indication of previous MUS, 5 were elective repeat CS, and the remaining 4 were for fetal indications. Eleven patients had spontaneous vaginal deliveries. There were no MUS-related pregnancy complications. One patient developed recurrent stress urinary incontinence postpartum, for which she underwent repeat MUS within a year resulting in cure of incontinence. This case series corroborates previous series demonstrating the safety and durability of MUS after subsequent pregnancy.